Periodontal Flaps

Definition
• Flaps: Periodontal flap is a section of gingiva and/or mucosa surgically
separated from the underlying tissues to provide visibility and access
to the bone and root surface. The flap also allows the gingiva to be
displaced to a different location in patients with mucogingival
involvement
Classification Of Flaps
• Periodontal flaps can be classified based on the following:
• Bone exposure after flap reflection
• Placement of the flap after surgery
• Management of the papilla
Classification of Flaps
• Based on bone exposure after flap reflection
• Full thickness flap (mucoperiosteal)
• Partial thickness flap (mucosal)
• Based on flap placement after surgery
• Non-displaced flaps
• Displaced flaps
• Based on management of the papilla
• Conventional
• Papilla preservation flap
Based on Bone Exposure
• Full Thickness Flap:
• A flap that includes epithelium, connective tissue, and periosteum
is referred to as a full-thickness or mucoperiosteal flap, and it is the
most common type of flap used when access to the bone is
indicated for resective or regenerative procedures

• Partial Thickness Flap:

• When the periosteum is not included in the flap, it is called a
partial-thickness or split thickness flap. This type of flap is used
extensively in mucogingival surgery to leave an underlying blood
supply where soft tissue grafting is performed to correct
deformities in the morphology, position, or amount of gingiva.

• There are also instances in which part of a flap may be full

thickness and the other part may be partial thickness. This
combined technique is used in some mucogingival and
esthetic crown lengthening procedures.
Full Thickness Flap
Full Thickness Flap
Full-thickness flaps are prepared
by making an incision through
the mucosal layers and the
periosteum until the bone is felt.

A periosteal elevator is then

used to gently separate the
periosteum along with the
superficial mucosal layers from
the bone
Partial Thickness Flaps

Periosteum is retained over bone before placing a subepithelial

connective tissue graft.
Partial Thickness Flap

The incision splits connective tissue. The periosteum is retained over bone.
The partial-thickness flap
• Should not be attempted in
• areas where the gingiva is thin (1 mm)
• posterior areas of the mandible where the vestibule is shallow and access
is difficult

• The tip of the surgical blade is used to split the connective tissue
layer into two parts:
• one, which is left covering the periosteum,
• The other becomes part of the tissue flap

• The tissue forceps aid in the stabilization and retraction of the flap
margin as the dissection is carried first laterally, then apically
• This approach creates better visibility and reduces tension on the
flap
• Poor visibility and excessive tension may lead to flap perforation or
tearing of the delicate flap thus compromising wound healing
Based on Flap Placement
• Displaced Flaps
• Apically positioned flap at the level of the bone crest
• Coronally positioned flap
• Pedicle flaps
• Undisplaced flap
Based on Papilla preservation
• Conventional flap
• Papilla preservation flap
Conventional Flap
• In the conventional flap the interdental papilla is split beneath the
contact point of the two approximating teeth to allow reflection of
buccal and lingual flaps. The incision is usually scalloped to maintain
gingival morphology with as much papilla as possible.
• INDICATION:
1) the interdental spaces are too narrow, thereby precluding the
possibility of preserving the papilla.
2) when the flap is to be displaced.
Conventional Flap
Papilla Preservation Flap
• In order to preserve the interdental soft tissues for maximum soft
tissue coverage following surgical intervention involving treatment of
proximal osseous defects, Takei et al. (1985) proposed a surgical
approach called papilla preservation technique.
• Later, Cortellini et al. (1995b, 1999) described modifications of the
flap design to be used in combination with regenerative procedures.
• For esthetic reasons, the papilla preservation technique is often
utilized in the surgical treatment of anterior tooth regions.
Papilla Preservation Flap
• intra-sulcular incision at the facial and proximal aspects of the teeth
without making incisions through the interdental papillae

• intra-sulcular incision is made along the lingual/palatal aspect of the

teeth with a semilunar incision made across each interdental area.
Papilla Preservation Flap
• The semilunar incision should dip apically at least 5 mm from the line
angles of the teeth, which will allow the interdental tissue to be
dissected from the lingual/palatal aspect so that it can be elevated
intact with the facial flap.
Papilla Preservation Flap
• A curette or interproximal knife is used to free the interdental papilla
carefully from the underlying hard tissue.
• The detached interdental tissue is pushed through the embrasure
with a blunt instrument.
Papilla Preservation Flap
• A full-thickness flap is reflected with a periosteal elevator on both
facial and lingual/palatal surfaces.
• The exposed root surfaces are thoroughly scaled, and root planed and
bone defects carefully curetted.
Papilla Preservation Flap
• While holding the reflected flap, the margins of the flap and the
interdental tissue are scraped to remove pocket epithelium and
excessive granulation tissue.
• In anterior areas, the trimming of granulation tissue should be limited
in order to maintain the maximum thickness of tissue.
Papilla Preservation Flap
• The flaps are repositioned and sutured using cross mattress sutures
• A surgical dressing may be placed to protect the surgical area.
• The dressing and sutures are removed after 1 week.
Papilla Preservation Flap
Papilla Preservation Flap
Modified Papilla Preservation
• The modified papilla preservation technique (MPPT) was developed
in order to increase the space for regeneration, and in order to
achieve and maintain primary closure of the flap in the interdental
area (Cortellini et al. 1995c,d).
Modified Papilla Preservation
• When interdental sites are narrower, the reported technique is
difficult to apply.
• In order to overcome this problem, a different papilla preservation
procedure (the simplified papilla preservation flap) has been
proposed for narrower interdental spaces (Cortellini et al. 1999).
Modified Papilla Preservation
• This approach includes an oblique incision across the defect-
associated papilla, starting from the buccal angle of the defect-
associated tooth to reach the mid-interdental part of the papilla at
the adjacent tooth under the contact point.

• In this way,the papilla is cut into two equal parts of which the buccal
is elevated with the buccal flap and the lingual with the lingual flap.
• Periodontal flaps are used in surgical periodontal therapy to accomplish the following:
1. Access for root instrumentation
2. Gingival resection
3. Osseous resection
4. Periodontal regeneration

To fulfill this purpose, five different flap techniques are used:

1. Modified Widman flap
2. Undisplaced flap
3. Apically displaced flap
4. Papilla preservation flap
5. Distal terminal molar flap
Modified Widman
• In 1974, Ramfjord and Nissle published “the modified
Widman flap”

• Facilitates root instrumentation

• It does not attempt to reduce the pocket depth, but it

does eliminate the pocket lining

• Provides intimate postoperative adaptation of

connective tissue to tooth surfaces.
 Modified Widman
Step 1:
• The initial incision is a scalloped
internal bevel incision to the
alveolar crest starting 0.5 mm to
1 mm away from the gingival
margin.
• The papillae are dissected and
thinned to have a thickness
similar to that of the remaining
flaps.
Modified Widman
• Step 2: Full-thickness flaps are reflected 2 to 3 mm away from the
alveolar crest
Modified Widman
Step 3:
• A second crevicular incision is
made from the bottom of the
pocket to the bone in such a
way that it circumscribes the
triangular wedge of tissue
that contains the pocket
lining.
Modified Widman
Step 4:
• The interdental tissue and
the gingival collar are
detached from the bone
with a third incision
Modified Widman
Step 5:
• Tissue tags and granulation
tissue are removed with a
curette. The root surfaces are
checked and then scaled and
planed, if needed.
• Residual periodontal fibers
attached to the tooth surface
should not be disturbed.
Modified Widman
Step 6:
• Bone architecture is not corrected unless it prevents
intimate flap adaptation.
• Every effort is made to adapt the facial and lingual
interproximal tissue adjacent to each other in such a
way that no interproximal bone remains exposed at
the time of suturing.
• The flaps may be thinned to allow for close
adaptation of the gingiva around the entire
circumference of the tooth and to each other
interproximally.
Modified Widman
• Flaps are stabilized with sutures and covered with a periodontal
dressing.
Modified Widman

Pre operative Post operative

Undislaced Flap
• Provides root surface access
• Eliminates the periodontal
pocket
• Transgingival interdental
probing depth and the
mucogingival junction, must
be considered to evaluate
the amount of attached
gingiva that will remain after
surgery
Undisplaced flap

The location of two different areas where the internal bevel incision is made in
an undisplaced flap. The incision is made at the level of the pocket to discard
the tissue coronal to the pocket if remaining attached gingiva is sufficient. BP,
Bottom of pocket; MCJ, mucogingival junction
Undisplaced Flap
The following steps outline the undisplaced flap
technique.
Step 1: The periodontal probe is inserted into the
gingival crevice and penetrates the junctional
epithelium and connective tissue down to bone
(transgingival probing through sulcus).
Step 2: The mucogingival junction is assessed to
determine the amount of keratinized tissue.
Undisplaced Flap
Step 3: The initial placement of the submarginal scalloped
internal bevel incision is based on the transgingival interdental
probing depth and the mucogingival junction.
• The incision is made parallel to the long axis of the tooth and
directed down to the alveolar bone.
• The angulation of the incision may be altered depending on
the thickness of the gingiva, as well as the initial placement of
the submarginal scalloped incision, to produce a thin flap
margin.
• The thicker the tissue, the more apically the incision will end.
• A short mesial vertical incision may be employed to allow flap
release on the palate or to avoid extension of the horizontal
incision into the aesthetic area.

Step 4: Full-thickness flaps are reflected 1 mm apical to the

mucogingival junction.
Undisplaced Flap
Step 5: The crevicular incision is made in the gingival crevice
to detach the attachment apparatus from the root.
Step 6: The gingival collar and granulation tissue are
removed with curettes. The root surfaces are scaled and
planed.
Step 7: Osseous recontouring is performed to eliminate
defects and reestablish positive architecture.
Step 8: The flaps are coapted on the alveolar crest with the
flap margin well adapted to the roots. The flaps may be
trimmed and rescalloped if necessary.
Step 9: The flaps are stabilized with sutures and covered
with a surgical dressing.
Kirkland Flap
• In a publication from 1931, Kirkland described a surgical procedure to
be used in the treatment of “periodontal pus pockets”.
• The procedure was called the modified flap operation, and is basically
an access flap used to allow proper root debridement.
Kirkland Flap
(Undisplaced, Full Thickness, Conventional Flap)
Apically Repositioned Flap
(Displaced, Full thickness)
Distal Wedge Flaps
• If the secondary objective of surgery is resective and adequate
keratinized tissue is present buccolingually, two distal horizontal
incisions are placed in keratinized tissue.
• Described by Robinson and Braden and modified by several other
investigators.
• These techniques are called the distal wedge and the modified distal
wedge.
Triangular distal wedge

Incisions diverge as they approach the ridge and converge as they are extended distally.
The facial and lingual tissues are thinned before reflection of the flaps.

These incisions are best accomplished with an Orban knife or a 12B scalpel.
Triangular distal wedge
Distal Wedge
 Linear Distal wedge

Incisions diverge buccolingually toward the ridge. Parallel extending distally away from the
tooth.
A releasing "T" incision is placed for greater flap reflection / access to the underlying bone.
Healing after periodontal surgery
Healing after Gingivectomy
Healing after Apically repositioned Flap
Healing after Modified Widman Flap
Healing Probing Pocket depths
• All surgical procedures result in reduction in deeper pocket depths
• Surgical procedures result in greater short term reduction than long
term reduction
• Surgical procedure with bone recontouring results in greatest short
term reductions.
• Long term reduction data is inconclusive
Healing Attachment level
• Short and long term results of shallow sites show
attachment loss for both surgical and nonsurgical
treatments.
• In sites(≥7 mm), a greater gain of clinical attachment
is observed.
• Clinical attachment levels following surgery with and
without osseous resection, either no difference was
found or flap surgery without osseous resection
produced a greater gain.
• Lindhe et al. (1982b) developed the concept of critical
probing depth (CPD) in relation to clinical attachment
level change
Healing Bone
• Bone fill seen in angular defects.
• Marginal bone loss less than 1mm, but the remaining portion of the
original bone defect is refilled with bone.
• Bone fill range from 3.5mm to 1.5mm
• Three wall and two wall defects show better bone fill than one wall
defect(poor prognosis)
Gingival recession after Periodontal Surgery
• Gingival recession is an inevitable consequence of
periodontal therapy
• It is seen both following non‐surgical and surgical therapy
• Irrespective of treatment modality used, initially deeper
pocket sites will experience more pronounced signs of
recession of the gingival margin than sites with shallow
initial probing depths (Badersten et al. 1984; Lindhe et al.
1987; Becker et al. 2001).
A general finding in short‐term follow‐up studies of
periodontal therapy:
• Non‐surgically performed scaling and root planing causes
less gingival recession than surgical therapy.
• Surgical treatment involving osseous resection results in
the most pronounced recession.
Gingival recession after Periodontal Surgery
However, data obtained from long‐term studies reveal:
• Initial differences seen in amount of recession between various treatment
modalities diminish over time due to a coronal rebound of the soft tissue
margin following surgical treatment (Kaldahl et al. 1996; Becker et al. 2001)
• Lindhe and Nyman (1980) found that after an apically repositioned flap
procedure, the buccal gingival margin shifted to a more coronal position
(by about 1 mm) during 10–11 years of maintenance.
• In interdental areas denuded following surgery, van der Velden (1982)
found an up‐growth of around 4 mm of gingival tissue 3 years after surgery,
while no significant change in attachment levels was observed.
• A similar finding was reported by Pontoriero and Carnevale (2001) 1 year
after an apically positioned flap procedure for crown lengthening.
Characteristics of a Flap
• Maintaining an optimal blood supply to the tissue
• Base should be broad
• The recommended flap length (height)-to-base ratio should be no greater
than 1:2
• The incision should not be made on the papilla
• Design flap for adequate visibility without over exposure of bone
• Margins should be placed over sound bone
• Primary closure should be done
• To avoid tearing the mucoperiosteum, a deep single incision should be
made with firm and continuous stroke
The advantages of flap operations include
• Existing gingiva is preserved
• The marginal alveolar bone is exposed whereby the
morphology of bony defects can be identified and the
proper treatment rendered
• Furcation areas are exposed, the degree of involvement
and the “tooth bone” relationship can be identified
• The flap can be repositioned at its original level or shifted
apically, thereby making it possible to adjust the gingival
margin to the local conditions
• The flap procedure preserves the oral epithelium and
often makes the use of surgical dressing superfluous
• The post-operative period is usually less un -pleasant to
the patient when compared to gingivectomy
Key Points
• Periodontal access surgery should occur only once the patient has
demonstrated effective biofilm control.
• Surgery in the absence of effective biofilm control and maintenance
will result in failure and recurrence of disease
• The primary objective of periodontal access surgery is access for root
instrumentations.
• The secondary objective is pocket reduction through soft tissue
resection, osseous resection, or periodontal regeneration.
Sub-Gingival Curettage
Subgingival Curettage
• The word curettage is used in periodontics to describe the scraping of the gingival
wall of a periodontal pocket to remove the chronically inflamed tissue.
• The excisional new attachment procedure is a definitive subgingival curettage
procedure that is performed with a knife.
• Historically, it was thought this tissue hinders healing and new attachment, which
necessitate gingival curettage.
• However, when the root is thoroughly scaled and planed, and the biofilm and
calculus are removed, the inflammation in the tissue automatically resolves
without tissue curettage.
• Therefore, the use of curettage to eliminate the inflamed granulation tissue is
unnecessary.
• This should not be confused with the elimination of granulation tissue during flap
surgery.
Subgingival Curettage
• It has been shown that scaling and root planing with additional
curettage do not improve the condition of the periodontal tissues
beyond the improvement that results from scaling and root planning
alone. (Lindhe and Nyman 1985)
• In the anterior maxilla, gingival curettage and root planing apical to
the base of the periodontal pocket should be avoided.
• The removal of the junctional epithelium and the disruption of the
connective tissue attachment expose non diseased cementum.
• Root planing and the removal of non diseased cementum may result
in attachment loss and gingival recession.